Pathophysiology and management of urinary tract endometriosis

Endometriosis predominantly affects the pelvic reproductive organs but can also affect the urinary tract. A number of theories for the pathogenesis of endometriosis have been suggested, but the exact mechanisms remain elusive. Endometriotic lesions can be found on both the ureter and bladder, and the optimal therapeutic approach depends on the extent, depth, and location of these lesions. Medical approaches, including hormonal therapies such as GnRH agonists and oral contraceptives, tend to be a temporary measure, but can be useful in a preoperative setting or if the patient is unsuitable for surgery, and are also useful as a postoperative treatment. If surgical resection is deemed appropriate, laparoscopic management with or without robotic assistance of urological endometriosis is feasible and advisable. Newer techniques, such as nerve-sparing surgery, might help to decrease the risk of urinary complications following resection of deeply infiltrating endometriosis. This is a preview of subscription content, access via your institution Access options Access Nature and 54 other Nature Portfolio journals Get Nature+, our best-value online-access subscription 27,99 € / 30 days cancel any time Subscribe to this journal Receive 12 print issues and online access 176,64 € per year only 14,72 € per issue Buy this article - Purchase on SpringerLink - Instant access to the full article PDF. 39,95 € Prices may be subject to local taxes which are calculated during checkout Similar content being viewed by others

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We would like to thank Sahar Houshdaran of the University of California at San Francisco for her contributions to the genetics portion of this paper. For their review of the manuscript, we would also like to thank Ceana Nezhat of the Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, and Farr Nezhat of Nezhat Surgery for Gynecology/Oncology in New York. We also thank Gity Meshkat Razavi for her help with drawing up the original figures in this article. Author information Authors and Affiliations Contributions All four authors researched data for the article and wrote the manuscript. C.N., R.F., and L.K. took part in discussions of content. C.N. and R.F. reviewed and edited the manuscript before submission. Corresponding author Ethics declarations Competing interests The authors declare no competing financial interests. Supplementary information DIE at the bladder base. (download MP4 ) The sonographer evaluates the size, location, and extent of a deeply infiltrative endometriosis lesion at the bladder base. This type of assessment can aid a physician in understanding endometriosis as the cause of a patient's UTI-like symptoms and help them counsel the patient on operative planning. Preoperative knowledge of a bladder endometrioma informs the surgeon of whom to gather for an interdisciplinary surgical team, often including a laparoscopically trained urologist and/or minimally invasively trained gynaecology expert. Permission obtained from ISUOG; published by John Wiley and Sons Ltd. © Guerriero, S. et al. Ultrasound Obstet. Gynecol. 48, 318–332 (2016). (MP4 6757 kb) Laparoscopic treatment of endometriosis of the ureter with and without robotic assistance. (download MP4 ) In this video, multiple forms of urinary tract endometriosis are classified and laparoscopic management strategies described. First, ureterolysis of extrinsic (superficial) disease of the ureter is shown, using robotic assistance. Next, release of a choked ureter constricted by endometriosis is demonstrated and then ureteroureterostomy for intrinsic (deeply invasive) endometriosis necessitating excision of a segment of ureter is shown. Next, ureterolysis and peritoneal stripping with robotic assistance is described. Use of the CO2 laser for excision and vaporization of endometriotic lesions as well as the role of hydrodissection in protecting the ureter and other vital structures from harm is shown in all cases. Finally, two cases of laparoscopic segmental bladder resection of deeply infiltrating endometriosis are shown, one performed with robotic assistance and one without. In both cases, cystoscopy is routinely performed to guide operative cystotomy. Complete excision of the deeply infiltrating endometriosis is required, with a 5 mm margin. Following the excision, bilateral stents are placed in the ureters, and the bladder is closed with 4–0 through-and-through. With or without robot assistance, the operative surgeon must be comfortable and adept at laparoscopic suturing of the bladder. (MP4 107967 kb) PowerPoint slides Rights and permissions About this article Cite this article Nezhat, C., Falik, R., McKinney, S. et al. Pathophysiology and management of urinary tract endometriosis. Nat Rev Urol 14, 359–372 (2017). https://doi.org/10.1038/nrurol.2017.58 Published: Issue date: DOI: https://doi.org/10.1038/nrurol.2017.58